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PEflMITTEE NAME/ADDRESS (Lnclude Facilip~ Namr/Locarion fD~erenrl
<br />NAME pICkhTNIGE FNCCE:SING, ILC
<br />ADDRESSN E ~ ELK 1: I N E
<br />1311 NNENIMUCC LFiYc
<br />EYAN:iYI1LE Ih 47711
<br />FACILITY
<br />LOCATIOt~L~TGN CC biLyl
<br />k.'!'fN: AI t:.NHY, MAkAGFti
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR;
<br />f2-16) (i]~ 91
<br />`. K
<br />~`'"PERMIT NUMBER DISCHARGE NUMBER
<br />FROM
<br />MONITORING PERIOD
<br />YEAR ~ MO. DA . •~ i, „.- YEAR MO DAY
<br /> ^~ ~ ~~ t
<br />(29-21) (~2~2J} `]'~i~}T• (26-2]) (P6~lY) Wu m)
<br />Form Approved.
<br />"L `C F OMB No. 2040-0004
<br />Approval expires 0537-98 ,
<br />)5U8h 'F)
<br />F EIkAI LA~!~5
<br />FEFU5e AFEA FCAL 7C k[FCA7LIFE
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<br />NOTE: Read Instructions before co pleting this form.
<br /> (3 Card Ony) QUANTITY OR LOADING Onty) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53) (54-61) (3845) (46-53) (50-61) EX OF TYPE
<br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
<br />EI SAMPLE ~~ '"~ ~~~'~ ~ EfiAC ( Ii)
<br /> MEASUREMENT
<br />C u U u 1 U G #~ FlA'It~ ~ +1i!1,, , !+1 L ~ u ~ _ ~
<br />~ i{ ! ! 5 I'1 iI
<br />' I'ELUENI GkGSS VALUE RCq'UfREMq"hl~; ~ ~ ~~
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<br />-L US, CTAL SAMPLE O+) Oa. nY>r'q.,:fi ': ;,t
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<br />5 U S p 6 h L' L L' MEASUREMENT
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<br />CLICG, ~ETTLEAc[E SAMPLE '~i'~{, ^' '~:.. ;~°~~^' ttd ( i`_)
<br /> MEASUREMENT
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<br />FfLUEN'I GFO55 YALGE .I{i=ESUIFIEM~N'f Xc:°: ~ ~ L/I .
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<br />1hl:N, 'T'OTAL SAMPLE fir, ;.•,:~:•, r,t,':;.:; LGq
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<br />{ A S F E) MEASUREMENT ~
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<br />"FF'LULNI GT!GS5 VAIUE Fi~T9lRI?MtiNi ' ~ ~ +'•~' ~G&! JIY`6: ~ R/I `s., ~ '~- `
<br />IL ANU G}:t:ASE SAMPLE Ca4'E¢z` Otfir"~9 >•:44G;: LSLfiOfi ]5)
<br /> MEASUREMENT
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<br />d H U T i. ! A 1 is ~ N I FLAN 9 MEASUREMENT
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<br />1L ANC V t:AS SAMPLE » 's77C I li) GC9r, r, ,i 4'~r~.'.L ~?ri;{CL
<br />1 ~ U A L MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSO
<br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HERE NALLY E%AMINEO AND
<br />IN
<br />AND BASED ON MY TELEPHON E DATE
<br /> INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON :
<br />SIBLE FOR OBTAINING .~
<br />1 ~
<br />/t ~ L ( (-t THE INFORMATION, I BELIEVE THE SUBMITTED IN
<br />ACCURATE AND COMPLE-rE. I AM AWARE THAT TH
<br />PENALTIES FOR SUBMITTING FALSE INFORMATIO FORMATION IS TRUE,
<br />ERE ARE SIGNIFICANT
<br />N
<br />INCLUDING THE
<br />•
<br />f ,
<br />POSSIBILITY OF FINE AND IMPRISONMENT. SEE IB U.S.C. 4 1091 AND 33 U.S.C. IGNATUR OF PRINCIPAL EXECU VE ~ Z ~ ~ 1
<br />TYP DOR PRINTED maximum imnnslmment orl ~nuesena8 months end SUtle l~nee up ro f19,000 entl or
<br />p years.) OFFICER OR AUTHORIZED AGENT A
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<br />NUM8FI3,
<br />YEAR
<br />MO ~
<br />DAY
<br />COMMENTS AND FJCPLANA710N OF ANY VIOLATIONS (Relerence ell attachments here) ~y ~ ~~
<br />.fL UAY nVERAGE 7L F.ILfiI:::i CGNTKIT AVG. DUPING PFNICG ntFCE~FC. GL1 6 GFEASF. - S1E L.s.I.L, F. 5. T`_5 G
<br />iCTAL lnGN LIMITS LfLI 2E ~AIYEL, ANL SETTLEAbLF. 9CiICS LIEI~~'"j AFFLIFC FGF. C~70lY~,?~~.Hk FFECIL fVFk1-.F'l:.
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<br />maY R04belissd.." : , ,.._.~,(~~Rl:ACES EPA FORM T-40 WHICN MAY N03 ~~DJ .~ ., a.A C Z II C C C ] I 1 ~ ~ E s C - -, PAGE 1
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